Healthcare Provider Details

I. General information

NPI: 1043398522
Provider Name (Legal Business Name): KATHLEEN M. VARTY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 EAST NIZHONI BLVD.
GALLUP NM
87301-1337
US

IV. Provider business mailing address

P.O. BOX 1337
GALLUP NM
87305-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1268
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN071531
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP0208
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number4704155724
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704155724
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: